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Thread: Dictation not being done

  1. #1

    Default Dictation not being done

    We have a physician that is not completing the notes in the EMR. We have not billed anything out because the notes are either not done or completed. Visits are from as far back as January of this year.

    Question 1: is there a law that determines a time frame for dictation to be done? (office visits) Our Medicare is only 20% so mostly BCBS.

    Question 2: Alot of these patients paid co-pays? If this doctor does not do the dictation will we be obligated to give the co-pays back?

    I am hoping for additional "fuel" to get this dication done. The manager is not able to get the doctor to get it done.

    Please send "documented" information if you have any so I can share with them.

    Last edited by Rgreen0118; 05-04-2012 at 03:27 PM.
    Rhonda Green, CPC

  2. #2
    Join Date
    Apr 2007
    Louisville, KY


    Check your contract with BCBS. If you do not have documentation for the service, then the co-pay would be like any other payment--you cannot accept money for a service you cannot prove was furnished.

    While there is documentation in the Medicare Conditions of Participation, I am mostly familiar with those for the hospital. I cannot find where physicians are held to that standard--being the case, we must rely on basic documentation standards that relate to not billing undocumented care.

    Wish I had more to offer.
    Kevin B. Shields, RHIT, CPCO, CCS, CPC, COC, CCS-P, CPC-P, CPC-I

  3. #3
    Join Date
    Apr 2007


    You might find out your answer by looking at signature requirements. Every ins requires that dictation be signed within so many days of the service being provided. For example, Cigna states that notes should be signed "within a reasonable time frame, usually 48-72 hours after the encounter but certainly before the claims submitted". So that tells you that the dication should be done within a day or two so that the dictation can get done and be signed. The issue you are going to have now is that if you provider does finally dictate on the old dates of service how can he reasonably say that he remembers that encounter? An insurance company will question that if you are ever audited.
    Susie Corrado, CPC
    ENT Coding/Billing

  4. #4


    Does anyone know the time frame for Medicare/Medicaid?

    Terri Diaz, CPC
    Insurance Coordinator

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